Study Identifies Patients Who Should Not Undergo Surgery for a Snapping Hip Tendon

Released: 7/8/2011 3:55 PM EDT
Embargo expired: 7/10/2011 12:00 AM EDT
Source: Hospital for Special Surgery

Newswise — Researchers at Hospital for Special Surgery have identified a group of patients who may have increased difficulty for surgical treatment of a snapping psoas, a condition that usually develops because a teenager or young adult has a pelvis that grows faster than their psoas tendon. The study will be presented at the annual meeting of the American Orthopaedic Society for Sports Medicine (AOSSM), held July 7-11 in San Diego.

“The conclusion from this study is that you should be cautious about releasing the psoas tendon, particularly in cases where there is some structural instability in the hip, specifically increased femoral anteversion, because although the tendon may be causing pain, it is also providing some dynamic support to the hip so it can cause problems if it is released,” said Bryan T. Kelly, M.D., who led the study and is co-director of the Center for Hip Pain and Preservation (www.hss.edu/hippain) at Hospital for Special Surgery (HSS) in New York.

The study received the 2011 Herodicus Award given annually by the Herodicus Society at the AOSSM meeting for the best paper submitted by an orthopedic resident or sports medicine fellow.

The hip is a ball-and-socket joint where the head of the femur (thigh bone) rotates within the cup-shaped socket of the pelvis. The head of the femur is supported by an angled neck which joins to the long thigh bone. At the base of the femoral neck is a boney protrusion. The psoas tendon is one of two hip flexor tendons that attaches to this protrusion. When the pelvis grows faster than the psoas tendon, this tendon becomes tight and snaps over the pelvis during walking or other activity. This condition, which can be painful, is known as a snapping psoas tendon.

“The reason that it snaps usually has to do with the anatomy of the pelvis. We usually see it in adolescent hips where the pelvis is growing at a faster rate than the tendon can accommodate for the growth,” said Dr. Kelly. “Structurally the tendon is not long enough to accommodate the bony anatomy.”

Doctors usually treat a snapping psoas tendon with physical therapy that involves stretching and strengthening, anti-inflammatories and corticosteroids, but if this doesn’t work, doctors resort to surgically lengthening the tendon. Because the tendon does not have the ability to stretch, surgeons cut slits in the tendon in what is called a partial release of the tendon or a fractional lengthening. “You cut it in a way that allows the muscle to elongate,” Dr. Kelly said.

Studies have shown that arthroscopic and open surgery can achieve similar outcomes for this condition. Few studies, however, have studied whether abnormalities in hip structure, specifically femoral anteversion, can impact outcomes. In most people, the center of the femoral neck points toward the center of the hip socket. Femoral anteversion is a condition in which the center of the femoral neck leans toward the front of the socket. This causes the knee and foot on the affected side to rotate internally or twist toward the midline of the body.

In December 2006, HSS researchers started a prospective registry of all hip arthroscopy procedures performed during a three-year period, 2006 to 2009, by a single, high-volume arthroscopic hip surgeon, Dr. Kelly. The study presented at AOSSM included all patients who underwent a psoas tendon lengthening at the time of surgery, a minimum of six months follow-up, and a preoperative high-resolution computed tomography (CT) scan to detect femoral anteversion. Patients were not included in the study if they had previous tendon hip surgery or hip trauma.

Sixty-seven patients underwent arthroscopic lengthening of a symptomatic psoas tendon, either in isolation or in conjunction with treatment for hip impingement. CT scans showed that 19 of 67 patients had high anteversion. The researchers assessed clinical outcomes both before and after surgery with modified Harris Hip Score (MHHS) and Hip Outcome Score (HOS) questionnaires. These are commonly used to evaluate a patient’s ability to carry out specific activities that involve the hip: activities of daily living, such as climbing stairs, and athletic activities, such as running and jumping.

Prior to surgery, patients who had high anteversion scored significantly worse in terms of athletic activities on the HOS, but there was no difference in either questionnaire scores in terms of daily living activities. After surgery, patients who had high anteversion scored significantly worse on the MHHS questionnaire with regard to athletic and daily living activities, but the HOS scores were similar between the two groups. Twice as many patients who had high anteversion had to undergo revision surgery.

The researchers say the psoas tendon may be an important stabilizer in the hips of patients with high anteversion, and the tendon’s release in these patients may result in a delayed return to activities after surgery and inferior outcomes.

“The results of this study indicate that there are certain groups of patients that respond very favorably to surgical treatment of the psoas tendon, but there are other groups of patients that due to mechanical reasons, surgeons should exercise extreme caution in proceeding with any tendon release around the hip,” Dr. Kelly said. He said these patients should be considered for alternative treatment strategies.

Other authors of the study are lead author and orthopedic surgery resident Peter D. Fabricant, M.D., and Katrina Dela Torre, R.N., M.Sc., at HSS, and Asheesh Bedi, M.D., former HSS fellow now at the University of Michigan.

About Hospital for Special Surgery
Founded in 1863, Hospital for Special Surgery (HSS) is a world leader in orthopedics, rheumatology and rehabilitation. HSS is nationally ranked No. 1 in orthopedics, No. 3 in rheumatology, No. 16 in neurology and No. 18 in geriatrics by U.S. News & World Report (2010-11), has received Magnet Recognition for Excellence in Nursing Service from the American Nurses Credentialing Center, and has one of the lowest infection rates in the country. From 2007 to 2011, HSS has been a recipient of the HealthGrades Joint Replacement Excellence Award. A member of the NewYork-Presbyterian Healthcare System and an affiliate of Weill Cornell Medical College, HSS provides orthopedic and rheumatologic patient care at NewYork-Presbyterian Hospital at New York Weill Cornell Medical Center. All Hospital for Special Surgery medical staff are on the faculty of Weill Cornell Medical College. The hospital's research division is internationally recognized as a leader in the investigation of musculoskeletal and autoimmune diseases. Hospital for Special Surgery is located in New York City and online atwww.hss.edu.

For further information:

http://www.newswise.com/articles/study-identifies-patients-who-should-not-undergo-surgery-for-a-snapping-hip-tendon

From Medicine and Science in Sports and Exercise®

What is the Effect of Physical Activity on the Knee Joint?

A Systematic Review

Donna M. Urquhart; Jephtah F. L. Tobing; Fahad S. Hanna; Patricia Berry; Anita E. Wluka; Changhai Ding; Flavia M. Cicuttini

Authors and Disclosures

Posted: 03/14/2011; Medicine and Science in Sports and Exercise®. 2011;43(3):432-442. © 2011 American College of Sports Medicine

Abstract and Introduction

Abstract

Purpose: Although several studies have examined the relationship between physical activity and knee osteoarthritis, the effect of physical activity on knee joint health is unclear. The aim of this systematic review was to examine the relationships between physical activity and individual joint structures at the knee.
Methods: Computer-aided searches were conducted up until November 2008, and the reference lists of key articles were examined. The methodological quality of selected studies was assessed based on established criteria, and a best-evidence synthesis was used to summarize the results.
Results: We found that the relationships between physical activity and individual joint structures at the knee differ. There was strong evidence for a positive association between physical activity and tibiofemoral osteophytes. However, we also found strong evidence for the absence of a relationship between physical activity and joint space narrowing, a surrogate method of assessing cartilage. Moreover, there was limited evidence from magnetic resonance imaging studies for a positive relationship between physical activity and cartilage volume and strong evidence for an inverse relationship between physical activity and cartilage defects.
Conclusions: This systematic review found that knee structures are affected differently by physical activity. Although physical activity is associated with an increase in radiographic osteophytes, there was no related increase in joint space narrowing, rather emerging evidence of an associated increase in cartilage volume and decrease in cartilage defects on magnetic resonance imaging. Given that optimizing cartilage health is important in preventing osteoarthritis, these findings indicate that physical activity is beneficial, rather than detrimental, to joint health.

Introduction

The promotion of physical activity is a major public health initiative in western countries worldwide. It is well recognized that physical activity is beneficial in the management of numerous major health problems, including cardiovascular disease, mental illness, and obesity.^[31,43] However, the influence of physical activity on the development and progression of osteoarthritis (OA), particularly on weight-bearing joints such as the knee, is unclear. Given the prevalence of OA is predicted to increase in the coming decades and physical activity is being highly promoted,^[48] it is important that we understand the effect of physical activity on the health of the knee joint.

Although a large number of epidemiological studies have examined the relationship between physical activity and knee OA, the results are conflicting. Not only is there evidence to suggest that physical activity is detrimental to the knee joint^[12,40] but studies have also reported physical activity to have no effect^[17,27] and even be beneficial to joint health.^[13,36] A previous systematic review by Vignon et al.^[45] concluded that sport and recreational activities are risk factors for knee OA and that the risk correlates with the intensity and duration of exposure. Although this systematic review investigated a broad range of different types of activity, including daily life, exercises, sports, and occupational activities, only the results of six studies that examined sports activity were retained in the review after evaluation.

Moreover, although the knee joint is a complex, synovial joint consisting of a variety of different structures, and epidemiological studies have assessed the effect of physical activity on osteophytes,^[26,33] joint space width (as a surrogate measure of cartilage thickness),^[27,41,42] and subchrondral bone,^[46] no systematic review has summarized the effect of physical activity on individual joint structures. Given that previous studies have reported the development of osteophytes with physical activity, but no effect on joint space narrowing,^[40] it may be hypothesized that physical activity may have different effects on structures within the knee joint. The aim of this systematic review was to examine the effect of physical activity on the health of specific joint structures within the knee joint.

For further information: http://www.medscape.com/viewarticle/737716?sssdmh=dm1.702843&src=journalnl

AOSSM Press Releases

Vitamin D Lower In NFL Football Players Who Suffered Muscled Injuries, Study Reports 7/10/2011 SAN DIEGO, CA – Vitamin D deficiency has been known to cause an assortment of health problems, a recent study being presented at the American Orthopaedic Society for Sports Medicine’s (AOSSM) Annual Meeting in San Diego today, suggests that lack of the vitamin might also increase the chance of muscle injuries in athletes, specifically NFL football players. “Eighty percent of the football team we studied had vitamin D insufficiency. African American players and players who suffered muscle injuries had significantly lower levels,” said Michael Shindle, MD, lead researcher and member of Summit Medical Group. Researchers identified 89 football players from a single NFL team and provided laboratory testing of vitamin D levels in the spring 2010 as part of routine pre-season evaluations. The mean age of the players was 25. The team provided data to determine the number of players who had lost time due to muscle injuries. Vitamin D levels were then classified based on player race and time lost due to muscle injury. Twenty-seven players had deficient levels (<20 ng/ML) and an additional 45 had levels consistent with insufficiency (20-31.9 ng/mL). Seventeen players had values within normal limits (>32 ng/mL). The mean vitamin D level in white players was 30.3 ng/mL while the mean level for black players was 20.4 ng/mL. Sixteen players suffered a muscle injury with a mean vitamin D level of 19.9. “Screening and treatment of vitamin D insufficiency in professional athletes may be a simple way to help prevent injuries,” said Dr. Scott Rodeo, MD, Co-Chief of the Sports Medicine and Shoulder Service at the Hospital for Special Surgery. “Further research also needs to be conducted in order to determine if increasing vitamin D leads to improved maximum muscle function,” said Dr. Joseph Lane, MD, Director of the Metabolic Bone Disease Service at the Hospital for Special Surgery.” For further information: http://www.sportsmed.org/tabs/newsroom/AOSSMPressReleaseDetails.aspx?DID=810

AOSSM Press Releases

Study Shows Lace-up Ankle Braces Keep Athletes on the Court 7/8/2011 SAN DIEGO, CA – Lace-up ankle braces can reduce the occurrence of acute ankle injuries in male and female high school basketball players, according to research presented at the American Orthopaedic Society for Sports Medicine’s Annual Meeting in San Diego. The study demonstrated that the braces are effective for athletes both with and without a history of ankle injury. “We wanted to see whether the use of lace-up ankle braces is a viable option for injury prevention in high school basketball players,” said lead researcher, Timothy A. McGuine, PhD, ATC, with the University of Wisconsin-Madison. “Basketball has one of the higher rates for ankle injuries, and this study illustrates how a simple brace can help keep an athlete on the court.” Acute ankle injuries are typically the result of a traumatic event, often caused by the sudden stops and starts common to a sport like basketball, and can include sprains and fractures. The study focused on a total of 1,460 male and female basketball players (between the ages of 13-18) from 46 high schools across the US. Athletes were divided into a braced group, who wore a synthetic, fabric, lace-up ankle brace, and a control group with no brace. A total of 78 acute ankle injuries occurred in the control group, compared to 27 injures in the braced group. “Seeing more than three times the amount of acute ankle injuries without the brace is a telling statistic,” said McGuine. “Having more players wear a brace on a regular basis would help prevent injury.” Information on the effects of lace-up ankle braces on all lower extremity injuries is still limited and suggested for further research. For further information: http://www.sportsmed.org/tabs/newsroom/AOSSMPressReleaseDetails.aspx?DID=805

KNEE

ORTHOPEDICS July 2011;34(7):524.

Arthroscopic Medial Retinacular Imbrication for the Treatment of Recurrent Patellar Instability: A Simple and All-Inside Technique

by Hu Xu, MD; Chunli Zhang, MD; Guoxian Pei, MD; Qinsheng Zhu, MD; Yisheng Han, MD

Abstract

Proximal soft tissue realignment is the main surgical intervention for recurrent patellar instability. In recent years, all-inside arthroscopic procedures or mini-open surgeries have replaced traditional surgeries, which have more associated morbidity and poor cosmetic results. This article describes a simple and all-inside arthroscopic technique for the operative treatment of recurrent patellar instability. Using 2 epidural needles in several steps and no accessory portals required, the medial patellar retinaculum is imbricated to the desired tension. The combination of lateral release and medial retinacular placation obviously improves the patellar tracking compared with preoperatively.

Drs Xu, Zhang, Pei, Zhu, and Han are from the Department of Orthopedics, Xijing Hospital, Fourth Military Medical University, Xi’an, People’s Republic of China.

Drs Xu, Zhang, Pei, Zhu, and Han have no relevant financial relationships to disclose.

Correspondence should be addressed to: Hu Xu, MD, Department of Orthopedics, Xijing Hospital, Fourth Military Medical University, Xi’an, 710032, People’s Republic of China (xuhutiger1997@yahoo.com.cn).

Although >100 different surgical methods have been described for the treatment of recurrent patellar instability, the best choice remains controversial. Since various procedures in a number of studies have been proved effective, no gold standard surgery has been defined yet. Most surgeries typically involve 2 basic techniques: proximal soft tissue realignment and distal bony realignment. Proximal realignment generally is addressed by a combination of lateral retinacular release and imbrications of medial retinaculum. Traditional open surgical management ordinarily leads to poor cosmetic results; therefore, total arthroscopic techniques and arthroscopy-assisted mini-open medial reefing for the medial soft tissue realignment have been reported in recent years. ^1,2 However, most arthroscopic methods for medial retinacular plication either require special instruments or have relatively complicated procedures.

Almazán et al ³ introduced an arthroscopic technique for the repair of the shoulder rotator interval. Using 2 spinal cannular needles with several steps, the defect of the rotator cuff interval lesion could be repaired without accessory portals. Combining Almazán et al’s ³ method with previously reported knee arthroscopic techniques, we developed a simple and all-inside procedure for the treatment of recurrent patellar instability.

Surgical Technique

Surgery is performed with the patient under general or spinal anesthesia. The patient is positioned supine on the operating table with an inflated tourniquet applied to the operative extremity. The leg is sterilely prepped and draped in routine fashion. Using the standard inferolateral and inferomedial portals, routine diagnostic arthroscopy is performed to observe the lesion of menisci and cartilage, traumatic loose bodies (chondral or osteochondral fragments), and rupture of the anterior and posterior cruciate ligaments. Corresponding treatments including partial meniscectomy, chondroplasty, and removal of loose bodies are performed.

Particular attention should be paid to check the relationship of the patellar ridge with the femoral trochlear groove through range of motion of the knee and assessing patellar tracking from both inferolateral and inferomedial portals. Lateral tilt and overhang of the lateral patellar facet can be observed. The extent of laxity of the medial patellar capsuloligmentous complex and tightness of the lateral patellar retinaculum can be evaluated.

Two spinal needles (17F Weiss or Tuohy) are used for reefing the patellar medial retinaculum. A suture retriever is prepared by a needle and a suture loop with 1 end passed through the cannula of the needle (Figures ). A spinal needle is inserted into knee joint at the medial patellar edge, and under arthroscope the needle is retreated for 1 or 2 cm to make a proper suture loop for another needle passing (Figures ). At a medial 2 or 3 cm from the first needle on the skin, another needle is pierced into the joint posteromedially to make the inner exit as far away the medial edge of patella as possible. Within the joint, under arthroscopic view, 2 suture retriever loops are crossed (Figures ) and 1 end of the suture loop is pulled by a forceps to open the loop into a free suture (Figures ). After removal of 2 needles from the joint and leaving 2 sutures, the suture loop is pulled to deliver 1 end of the free suture out of joint to complete 1 stitch (Figures ). This procedure is repeated 3 or 4 times so that the stitches evenly spread from the superior pole to the inferior pole of the patella (Figure ). Using a giant needle subcutaneously passing through the 2 eyelets of 1 stitch on the skin, the end of suture at patella edge is brought to the far medial eyelet (Figures ).

Figure 1:. Two spinal needles, each with a suture loop, were inserted into the joint on the medial side of the patella (A). Under arthroscopic control, 2 suture retriever loops were crossed (B) and 1 suture end was pulled (C, arrow) to open the loop to a free suture (D). After removal of the needles, pulling 2 ends of a suture loop (E, arrow) brought another suture out of the joint (E, F) to complete a stitch. Bold arrow: bruise of medial patellofemoral ligament. The procedure was repeated several times so that the stitches (arrowheads) evenly spread from the superior to the inferior pole of the patella (G). Abbreviations: FC, femoral condyle; P, patella.

Figure 2:. A giant needle passing through the inlet and outlet of the stitch subcutaneously (A, arrow) led the suture end at medial patellar edge out from the far medial eyelet (A, B). Abbreviations: IM, inferomedial portal; P, patella.

The camera is switched from the inferolateral portal to the inferomedial portal to get a better view of the lateral retinaculum. In most patients with recurrent patellar instability, after debridement of the lateral synovium of the patella by a 4.5-mm Linvatec soft tissue shaver (Largo, Florida), a radiofrequency device is inserted in the joint through the inferolateral portal to perform lateral retinaculum release. A full-thickness retinaculum cut is made from the superior pole of the patella to the inferior pole at 1 cm lateral to the patella.

The assistant manually tightens the sutures at medial side of the patella, and patellar tracking is evaluated again from full extension to 90° of flexion under arthroscope. After medial plication and lateral release, the new relationship of the patellar ridge with the femoral sulcus can be observed. Furthermore, it is found that lateral tilt and overhang of lateral patellar facet are vanished or improved. At the same time, it also can be found that the patella is pulled medially from apparent view. Based on re-evaluation of patellar congruency in the trochlea and tracking, we regulate the tension of medial retinaculum imbrication to avoid internal tilt in case of excessive medialization of the patella.

Then the fluid of the joint is drained and the sutures tightened and knotted 1 by 1 when the assistant pushes the patella medially and maintains the tension according to the reevaluation under arthroscope (Figure ). After this procedure, we check the joint under arthroscope again to make sure patellar tracking is satisfied, and then bury the knots subcutaneously (Figure ).

Figure 3:. After re-evaluation of patellar tracking, the sutures were tightened and knotted with the knots buried subcutaneously (A, arrowheads). The medial reefing (arrowhead) was checked again under arthroscope (B). Bold arrow: bruise of medial patellofemoral ligament. Abbreviations: FC, femoral condyle; IL, inferolateral portal; IM, inferomedial portal; P, patella.

Postoperatively, as a part of standard rehabilitation program, quadriceps contractions and straight-leg raises are encouraged immediately after anesthesia fades. After 2 weeks, the patient is allowed to partially bear weight with crutch support and brace protection. Full weight bearing is allowed at 4 weeks. The brace is unlocked to enable patients to begin range of motion exercises not beyond 60° and 90° every 2 weeks. At 4 weeks, the patient is allowed to increase knee flexion as tolerated.

Results

To date, 17 patients with recurrent patellar instability have been treated by this all-inside arthroscopic technique. Traumatic chondral or osteochondral fragments were found in 4 cases, and 3 of them underwent chondroplasty. In 2 cases, lesion of the menisci was found and corresponding partial meniscectomy was performed. No anterior and posterior cruciate ligament rapture was found. No operational complications such as intra-articular infection or iatrogenic injury were observed. Mean operative time was 48.4±6.7 minutes (range, 39–61 minutes), whereas average time for medial imbrication was 23.2±4.9 minutes (range, 17–35 minutes). Furthermore, in the latest 5 cases performed in the past 12 months, medial reefing was performed in <20 minutes.

Postoperatively, 3 patients have been followed for >2 years, 7 patients for 1 year, and 5 patients for <1 year. Two patients were lost to follow-up. No recurrence of patellar subluxation or luxation has been found. On physical examination, all patients had a normal patella tracking and good stability in response to manual translation of the patella. One patient who failed to follow standard rehabilitation program had significant loss of range of motion (from 5° to 95°) 7 months postoperatively.

Discussion

For the treatment of patellar dislocation, many open procedures, including soft tissue realignment and bony procedures such as Elmslie-Trillat, ⁴ Roux-Goldthwait, ⁴ Hauser, ⁵ Insall proximal realignment, ⁶and combined realignment procedures, ⁷ have been popularized in the past. Although these traditional operations have proven to result in successful clinical outcomes to a varying extent, they generally accompany apparent morbidity and poor cosmetic results. Nevertheless, the recent progress of knee arthroscopy provides the possibility of minimally invasive procedures for proximal realignment of the patella.

Our technique does not require special instruments, complicated surgical skills, or accessory portals. The procedure is simple and easy for surgeons to perform. Halbrecht ⁸ reported an all-inside technique for proximal patella realignment under arthroscopy. Using 1 epidural needle toward 2 different directions subcutaneously, the medial retinaculum and capsule were penetrated twice so that the suture was introduced to create a loop for knotting. Compared to our technique, the disadvantages of Halbrecht’s ⁸method are: (1) it requires an accessory superolateral portal; (2) the second stab through the retinaculum by epidural needle subcutaneously is difficult to precisely control the position of the outlet and the span of a stitch; and (3) it takes more time and more complicated skills to knot 4 or 5 times in the joint under arthroscope rather than freehand knotting outside the joint.

In 2002, Haspl et al ⁹ developed another all-inside method with some instruments including a working cannula and Transporter Suture Retriever (Acufex, Mansfield, Massachusetts). In their method, an accessory superomedial portal was needed, and 4 or 5 arthroscopic knots were formed and slid down through the extra-articular cannula. Compared to our technique, their procedure is relatively complicated, and the span of the stitch is limited since the inlet and the outlet are perforated from a cannula through the same superomedial portal.

In 2007, Ali and Bhatti ¹ reported a technique to reef the medial retinaculum with a long and prebent 16-gauge Tuohy needle, meniscal suture needle, and artery forceps, which created a subcutaneous plane to retrieve sutures. Their method is not simpler than Haspl et al’s ⁹ since 4 portals (inferolateral, inferomedial, superolateral, and midmedial parapatellar) are needed. According to Ali and Bhatti, ¹ the inlets of the stitches are not close to the medial edge of the patella, mainly as a result of the difficulty of bending a metal 16-gauge Tuohy needle precisely for perforating the capsule twice in aimed positions.

In 2006, Schöttle et al ¹⁰ reported a similar technique, with 2 differences compared to our method: (1) the first needle is pierced through the periosteum of the medial patellar facet, which may lead to avulsion of the insertion on the periosteum as a result of the high tension of knotting in medial imbrication; and (2) an eyelet is advanced through the subcutaneous tissue and is pressed against the skin, where a second epidural needle is inserted through the eyelet into the joint. It may be not easy for a needle to pass through the subcutaneous eyelet precisely.

Although some studies show the clinical success of isolated lateral retinacular release for the treatment of recurrent patellar dislocation, ¹¹ a recent systematic review combining the results of 14 studies concludes that compared with lateral release and medial soft tissue realignment, lateral release alone yields significantly inferior long-term results with respect to symptoms of recurrent lateral patellar instability. ¹² In our technique, we performed both lateral release and medial retinacular imbrication for patients, and no recurrence of patellar subluxation or luxation has been found. After full-thickness lateral release, the patella could be pushed medially by an assistant and medial plication performed. In 2010, Dodson et al ¹³ performed plication first and then released the lateral retinaculum. However, based on clinical experience, we believe that the initial lateral release would provide suitable conditions to further medial plication and knotting the sutures with desired tension. Furthermore, it is incorrect to knot the sutures as tightly as possible in medial reefing. An in vitro study has implied that proximal soft tissue realignment may result in significantly medialized and internally tilted patellar movement. ¹⁴ We suggest that the knotting should be adjusted to appropriate tension according the re-evaluation of patellar tracking under arthroscope.

Our technique is performed in patients with recurrent patellar instability combined with acute injury of the medial patellofemoral ligament body (Figures , , ), since imbrication provides a tension-free condition for ligament healing.

Indications for our technique include recurrent patellar instability resulting from laxity of the medial retinaculum, injury of the medial patellofemoral ligament body, and cases without serious trochlear dysplasia, patella alta, and a considerably high Q angle. However, for the treatment of most severe osseous abnormalities, such as significantly high Q angle, serious patella alta, or trochlear dysplasia, distal bony realignment procedures should be initially considered rather than our technique. Moreover, theoretically our technique is unsuitable for some special types of patellar instability even with a normal Q angle. For example, in cases of avulsion of the medial patellofemoral ligament from the patellar side, ligament reattachment on the medial patellar facet or the reconstruction of the medial patellofemoral ligament is a better choice. ^13,15 In another unpublished study by our medical group, we used anchors for the treatment of patellar instability combined with avulsion of the medial patellofemoral ligament.

Conclusion

The advantages of our technique include simple steps, no special instruments, no accessory portals, and ease of manipulation for arthroscopists. The pitfalls include the limitation that it cannot be performed when the medial patellofemoral ligament has been avulsed off the femoral or patellar side, and that the sharp tip of the spinal needles may cut off the sutures when they pierce into the joint.

For further information: http://www.orthosupersite.com/view.aspx?rid=85222

KNEE

Posted on the ORTHOSuperSite July 8, 2011

Study pinpoints risk factors for TKA following knee arthroscopy

SAN DIEGO — Older age and lower surgeon volume are key risk factors for patients ofknee arthroscopy to undergo total knee arthroplasty within a year of the procedure, according to a recently presented study.

“If a patient undergoes knee arthroscopy shortly before [total knee arthroplasty] TKA, arthroscopy may have been an accessory,” Hassan Ghomrawi, PhD, said during his presentation at the 2011 Annual Meeting of the American Academy of Orthopaedic Surgeons.

He noted that previous research suggests that 5% to 10% of patients who had a knee arthroscopy undergo TKA within a year of the procedure. “Although we know surgeons have a major role in the decision making when doing an arthroscopy, these epidemiologic studies did not evaluate the effect of surgeon characteristics or volume on outcome.”

Ghomrawi’s team used a New York database to identify 188,575 patients older than 40 years of age who underwent knee arthroscopy between 1999 and 2005. The team traced patient identifiers to locate those who underwent TKA within a year of their arthroscopy. The odds ratio model used for the study took into account gender, insurance type, comorbidities, diagnosis, type of arthroscopy and the yearly arthroscopy volume of the surgeon.

Ghomrawi and colleagues found that 42,833 patients in the study were diagnosed with arthritis. Overall 4,536 patients (2.4%) went on to receive TKA within a year of their arthroscopy.

Patients who were 70 years or older, female, had arthritis, were insured by Medicare or Medicaid and those who underwent arthroscopy with a surgeon whose workload was less than 12 arthroscopies per year were found to be more likely to undergo a subsequent TKA.

The risk of undergoing a TKA decreased with ACL reconstruction and meniscectomy.

“Our results highlight the significance of volume-outcome relationships, and call for further investigation in this area,” Ghomrawi concluded.

For further information: http://www.orthosupersite.com/view.aspx?rid=85511

FOOT AND ANKLE

ORTHOPEDICS July 2011;34(7):530.

Achilles Tendon Rupture and Subsequent Repair

by Keith L. Wapner, MD

Dr Wapner is from the University of Pennsylvania, Philadelphia, Pennsylvania.

Dr Wapner has no relevant financial relationships to disclose.

Correspondence should be addressed to: Keith L. Wapner, MD, 230 W Washington Sq, 5th Floor, Philadelphia, PA 19106.

What are the leading causes of Achilles tendon rupture?

Achilles tendon injuries are deceleration injuries. They occur when the gastrocsoleus muscle forcibly retracts, such as when you land after going up for a rebound in basketball, causing a sudden unexpected dorsiflexion to the ankle. They can occur while pushing off with the knee extended, as in tennis while lunging for a shot. They can also occur with sudden violent dorsiflexion force on a plantar flexed foot. These traumatic ruptures occur because the force exerted on the suddenly rapidly loaded tendon exceeds the tendon’s tensile strength.

What is your technique for an Achilles tendon repair?

I generally do an open repair of the Achilles tendon using a nonabsorbable suture. I use a medial approach just anterior to the Achilles tendon to avoid a posterior scar and to avoid the sural nerve laterally. Dissection is always done deep to the paratenon to avoid injury to the blood supply to the skin. The goal is to debride any devitalized tissue and then anastamose the ends of the tendon back to restore the normal resting length of the muscle, to avoid overlengthening and subsequent weakness. I use a modified Bunnell-type stitch but generally place 2 to 3 passes depending on the degree of mop-handle tearing. Postoperatively, I begin active range of motion and protected weight bearing at 4 weeks and strengthening at 8 weeks.

What is your cut-off for a primary repair, and how do you treat one if it is past your cut-off?

I do not have a cut-off for primary repair of the tendon, but if the rupture is older than 3 months, if the tendon ends are devitalized, or if I have any difficulty getting the ends of the tendon opposed, I will add a flexor hallucis longus tendon transfer to reinforce the repair and give better strength to the tendon.

How do you treat chronic Achilles tendinosis? When do you operate?

I will initially try nonoperative treatment. If the tendinosis is severe, I first immobilize the patient in a molded ankle-foot orthosis until the tenderness is diminished. I start range of motion exercises, then advance to theraband strengthening and eccentric exercises. I wean the patient out of the orthosis and continue with these exercises. If the tendinosis is not severe, I start with the therapy first. If this is not successful in resolving the patient’s pain, or if the patient does not wish to try nonoperative treatment, I give them the option of surgery with debridement of the tendon and flexor hallucis longus transfer. I will harvest the flexor hallucis longus from a separate midfoot incision and pass it through a hole in the posterior calcaneus, then weave the flexor hallucis longus up through the Achilles.

Which patients benefit from nonoperative treatment of an Achilles tendon rupture?

In the acute setting, patients who are not operative candidates because of concomitant medical problems benefit from nonoperative treatment. Some studies show that closed treatment will give satisfactory results, but most of these rely on serial ultrasound studies to assure that the tendon ends are opposed to prevent healing with an overlengthened tendon.

In the setting of chronic tendinosis, patients who do not wish to significantly limit their activity or undergo surgery can be managed with molded ankle-foot orthosis bracing.

What should the physical examination entail for an acute Achilles tendon rupture?

The classic test for an Achilles rupture is the Thompson test. The examiner lays the patient prone with the foot extending past the end of the examination table, then squeezes the calf muscle. If the patient’s foot does not plantar flex, this indicates that the tendon is ruptured. This can also be done prone with the patient’s knee flexed. At times, a palpable gap may be present in the tendon, but this is less reliable. Plantar flexion against resistance is also unreliable, as the patient may be able to generate significant plantar flexion force with the flexor hallucis longus and flexor digitorum longus muscles.

What is the role of imaging in diagnosing acute Achilles tendon ruptures?

Generally, imaging other than radiographs to rule out concomitant fractures is not required. If the diagnosis is not clear on physical examination, it can be confirmed by sonogram or magnetic resonance imaging.

Does immediate mobilization following Achilles tendon rupture surgery lead to a quicker recovery?

Immediate mobilization should be delayed until there is either surgical repair of the tendon or sonogram evidence of healing of the tendon ends if nonoperative treatment is used. Early mobilization has been shown to improve functional long-term results and is widely accepted.

What does the future hold for the treatment of Achilles tendon rupture?

The use of biologics may lead to earlier and enhanced healing of the Achilles tendon. This is an area where further research and ongoing studies may provide us with better treatment options.

In this issue of ORTHOPEDICS, Dr Keith L. Wapner discusses his technique for Achilles tendon repair and which patients may benefit from nonoperative treatment.

For further information:

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